Decision Aids: Facilitating Communication with Cancer Survivors

Linking physicians and patients is a major undertaking, but given the ubiquity of smartphone technology and the rise in app development, the healthcare industry is poised to leverage advances in communication and information exchange. At the 2016 Cancer Survivorship Symposium, Steven J. Katz, MD, MPH, Professor of Medicine and Health Management and Policy, University of Michigan, Ann Arbor, discussed the use of deliberation
systems to enhance communication with survivors and their care.

“There is a bright future for treatment deliberation systems, which will play an adjuvant role in decision-making, but they need to be integrated into the workflow in a way that physicians buy off on,” said Dr Katz. “There are virtually no good data about the utilization of these tools in treatment settings, let alone posttreatment and into survivorship,” he said.

Nevertheless, these studies show that decision aids improve patient knowledge and engagement, and enhance patient appraisal of decision-making, with no systematic impact on treatment.

Cancer is an ideal tracer disease for the implementation of these aids, Dr Katz suggests, but context is critical. In breast cancer, for example, nearly all the treatments that confer lifetime benefits are initiated and, for the most part, completed in the first year. In addition, treatment decision-making is increasingly algorithmic and complex compared with other types of cancer.

Because of the advance of precision medicine, treatment decision aids must fit within structured discussions and proactive recommendations from medical oncologists regarding chemotherapy. In addition, the majority of patients are treated by the first clinician who they see.

“In the states of California and Georgia, over 90% of patients are treated by the first medical oncologist that they see, and over 90% by the first surgeon that they see,” said Dr Katz. Although breast cancer treatment is becoming more algorithmic, the timing of tests and treatment decisions can still be chaotic.

“About one third of patients hear about their diagnosis from a radiologist,” said Dr Katz. “By the time they walk into the [oncologist’s] room, they often know the diagnosis and are already thinking about it.”

Reason versus Intuition

Treatment-related decision-making tools focus on rational deliberation in the evaluation of trade-offs between treatment options and offering knowledge and information about those options. This rational approach, according to Dr Katz, is relatively insensitive to how people actually make decisions in the examination room, which is a predominantly intuitive process comprised of counterfactual thinking and heuristics.

When evaluating their treatment options, some patients may rely on personal examples (eg, a friend’s unpleasant side effects of chemotherapy), and others may be driven toward more radical measures because of an aversion to uncertainty.

“How do we design decision tools to address these heuristic and counterfactual processes that are difficult to elicit in patients?” he asked. “Women often talk about the need for peace of mind. Can that be addressed in the context of treatment decision-making?”

Lack of Knowledge

Despite the abundance of available information, patients’ knowledge about their disease can still be surprisingly lacking.

In a survey of patients with breast cancer that was conducted shortly after their diagnosis, Dr Katz and colleagues found that 25% of patients markedly overestimated their distant recurrence risk after treatment, and 75% of patients did not know that breast-conserving surgery is equivalent to mastectomy in terms of survival.

“Clearly, patients don’t always walk away with the kind of knowledge that we want them to have. Fixing that is going to be an interesting challenge,” said Dr Katz.

“We talk about patients’ preferences for treatment,” he said, “but we talk less about patients’ preferences for how decisions are made. For every patient who says, ‘I want to make the decision,’ there are potentially 2 who want their doctors to make the decisions for them.”